Unlocking Growth: How Claims and Transparency Data Can Transform Your DMEPOS Business

Published in Member Communities on December 22, 2025

By Ryan Ball, Vice President, VGM Market Data

Healthcare providers across the DMEPOS and CRT sectors are increasingly turning to data to guide strategic growth. Organizations can now use claims data and price transparency tools. This helps them make better decisions about market expansion, targeting referrals, and optimizing payer contracts.

There is a powerful framework for using data to uncover new opportunities and strengthen provider positioning across all segments of the medical equipment industry. 

Why Data-Driven Market Assessments Matter

With the rise of payer transparency regulations and the availability of remitted claims data, providers can now:

• Analyze market size by product and geography
• Identify high-volume referral sources
• Understand competitive provider market share
• Compare payer reimbursement rates
• Justify payer contract negotiations

These insights help providers make informed decisions about expanding into new markets, how to compete, which contracts to prioritize, improving payer relationships, or optimizing their current operations.

Five Steps to Smarter Market Strategy

1. Quantify Market Opportunity

Use claims data to estimate demand for specific HCPCS codes in your target area. Understanding the total volume in a targeted geography helps quantify market potential and determine your next market expansion opportunity. Whether you’re evaluating power mobility, prosthetic limbs, or orthotic braces, understanding volume is key.

2. Identify Referral Sources

Understanding referral sources is essential for strategic growth in the DMEPOS industry. Claims data can reveal which physicians, clinics, or facilities are consistently referring patients for specific products, helping providers identify both loyal partners and untapped opportunities. By analyzing referral patterns, organizations can pinpoint high-volume sources, detect referral leakage to competitors, and uncover providers who may be referring for related services but not yet for DMEPOS. Segmenting these sources by specialty, geography, and volume allows for more targeted outreach and relationship-building.

Consider this scenario: A mobility equipment provider used referral data to identify a high-volume orthopedic clinic that was exclusively referring to a competitor. After initiating a personalized outreach campaign and demonstrating superior service quality and patient satisfaction, the provider successfully captured a portion of those referrals—resulting in a 20% increase in monthly orders.

By leveraging referral insights, providers can personalize engagement strategies, develop educational materials tailored to specific needs, and track changes in referral volume to measure the impact of their efforts. 

3. Analyze Competitive Landscape 

Evaluate which providers dominate specific regions or facilities. Are there underserved areas or facilities overly reliant on one provider? 

4. Evaluate Payer Mix and Reimbursement Rates

Not all volume is profitable. Some payers reimburse significantly more than others for the same HCPCS codes, and some contracts may carry hidden administrative burdens that impact your bottom line.  By analyzing claims data, providers can compare reimbursement rates across payers, identify underperforming contracts, and uncover gaps in coverage that may be limiting patient access or revenue potential.

It’s also important to look beyond rates alone; consider metrics like denial frequency, time to payment, and contract terms that affect operational efficiency. For instance, a provider may find that while one payer offers higher reimbursement, it also has a higher denial rate and longer payment cycles—making another payer with slightly lower rates but faster processing a better strategic fit. This kind of analysis helps providers prioritize which contracts to renegotiate, which payers to cultivate stronger relationships with, and where to focus expansion efforts based on financial viability.

5. Justify and Negotiate Better Contracts

Armed with data, you can approach payers with a compelling case for improved rates—especially when you can demonstrate value through patient outcomes, service quality, or geographic reach.

Real-World Examples: Market and Payer Analysis in Action

In two case studies:

• Current Market Review: In one state, five insurers controlled 95% of covered lives. By comparing reimbursement rates, providers identified which contracts needed renegotiation. 
• New Market Evaluation: In California, six major health plans covered 98% of commercial lives. By analyzing payer mix, referral volume, and average reimbursement, providers estimated revenue potential before entering the market.

Commercial Reimbursement Data: A Game-Changer

The Transparency in Coverage Rule requires insurers to publish machine-readable files with negotiated rates and out-of-pocket estimates. This allows providers to:

• Benchmark their rates against competitors
• Identify underpaid services
• Understand payer dynamics in new markets

While commercial reimbursement data from the Transparency in Coverage Rule offers valuable insights, it’s important to understand its limitations before relying on it for strategic decisions. The data excludes key segments such as Medicare Advantage and Medicaid, which can significantly impact market analysis depending on your patient mix. Additionally, the machine-readable files published by insurers can be difficult to interpret without specialized tools or expertise, and the data may not always be current or standardized across payers. Providers should also be cautious of missing context—negotiated rates alone don’t reflect denial rates, administrative complexity, or patient outcomes. To get a more complete picture, it’s best to supplement transparency data with internal billing records, remitted claims data, and payer performance metrics. When used in combination, these sources can help providers benchmark rates more accurately, identify underpaid services, and better understand payer dynamics in both existing and new markets. 

Final Takeaways for Healthcare Equipment Providers

To grow your business in today’s competitive landscape:

• Know before you go: Use data to evaluate new markets.
• Define opportunity clearly: Focus on product-specific and geographic insights.
• Understand payer dynamics: Compare reimbursement rates and contract terms.
• Make data-driven decisions: Let the numbers guide your strategy.

Data doesn’t make decisions for you, but it makes your decisions better. Want to learn more about how VGM Market Data can support your growth strategy? Contact VGM Market Data here or call 866-394-6868. 

This article was originally featured in the "VGM Playbook: Disrupting the Traditional HME Strategy." To read the full article and more like this, download your copy of the playbook today! 

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